High Deductibles Tied to More ED Visits for Low-Income Diabetics

— Similar trends reported among HSA-eligible patients with diabetes

by Kristen Monaco,Contributing Writer, MedPage Today
January 9, 2017

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After switching from a low-deductible healthcare plan to a high-deductible healthcare plan, low-income and HSA-eligible patients with diabetes showed a significant increase in emergency departments visits deemed to have been preventable, researchers reported.

The interrupted-time-series study found that patients switching to a high-deductible healthcare plan (HDHP) had an 8% annual increase in preventable ED visits for acute diabetes complications (95% CI 4.6%-11.4%), according to J. Frank Wharam, MB, BCh, BAO, MPH, of Harvard Medical School in Boston, and colleagues.

Note that HDHPs have become the predominant commercial health insurance arrangement in the U.S. and are expected to play a major role in the future of U.S. health policy.

Patients with low incomes experienced an especially large increase (21.7%, 95% CI 14.5%-28.9%), and the HSA-eligible subgroup had a 15.5% rise in visits (95% CI 10.5%-20.6%).

Published in JAMA Internal Medicine, the study examined individuals with diabetes before and after an employer-mandated switch from a low-deductible to HDHP in terms of emergency department visits related to preventable diabetes complications, outpatient complication visits, disease monitoring visits, and out-of-pocket medical expenses.

Due to the growing popularity of HDHPs, the researchers aimed to determine whether or not the higher upfront associated costs would lead to putting off more expensive care and testing. "It also appears that high-deductible plans associated with health savings accounts will be the centerpiece of the new presidential administration's plan to replace the Affordable Care Act," Wharam explained to MedPage Today.

"We decided to examine how high-deductible health plans affect people with diabetes because these patients often need frequent, expensive healthcare services and no studies have examined adverse outcomes among chronically ill patients in high-deductible plans. Skipping or delaying needed diabetes care could cause patients to be sicker in the future and could therefore increase the need for more expensive or higher acuity care," said Wharam.

The study also found small but significant delays in outpatient visits for acute diabetes complications among both the overall group as well as the low-income group compared with individuals who remained on low-deductible plans.

Despite a small decline in high-priority specialist visits among patients with diabetes in the two years following a switch to a HDHP, overall rates of specialist visits and testing for disease monitoring, which included HbA1c, LDL, microalbumin, and retinal testing, did not significantly change.

"The majority of diabetes patients enrolling in high-deductible plans did not experience the adverse health outcomes we measured, but vulnerable subgroups such as those with low incomes or additional chronic conditions, had evidence of adverse outcomes such as increased emergency department visits for acute complications," Wharam said in an interview. "Our results indicate that more tailored health insurance plans might be needed."

Participant data was collected through commercially insured employees in the Optum database. Researchers matched insured patients with diabetes who switched to a HDHP (≥$1,000) 1:1 with a control of patients who continued with a low-deductible healthcare plan (≤$500) (n=12,084 for both).

Using an original system classifying a "complication visit" as a preventable diabetes-related complication by seeking treatment sooner, the researchers reported the five most common emergency department related visits included cellulitis, urinary tract infection, hypoglycemia/hyperglycemia, angina/ischemic heart disease, and pneumonia.

While the classification methods of a "complication visit" may be subjective, the researchers note that measurement error could limit results through a potential "lack of consensus regarding which diagnoses are considered 'acute preventable diabetes complications.'"

In an invited commentary, A. Mark Fendrick, MD, of the University of Michigan, and Michael E. Chernew, PhD, of Harvard Medicine School, commended Wharam and colleagues on their novel research of health outcomes related to consumer-cost sharing with health insurance. In particular, Fendrick and Chernew highlighted that the most important result of the study is to understand that "while consumer cost-sharing may not have large deleterious health effects on the general population, low income and very sick populations are particularly vulnerable to cost-related nonadherence."

Citing the growing underinsured population and lack of consumer ability to distinguish "high-value and low-value clinical services," Fendrick and Chernew advocated for a transition towards a value-based insurance design. "By expanding predeductible coverage for essential care and directing high deductibles on to low-value services (e.g., services identified by the Choosing Wisely initiative), this 'High-Value Health Plan' (HVHP) would provide more effective coverage without fundamentally altering the original intent and spirit of consumer-directed plans," they concluded.

Wharam concluded that his best advice for patients with diabetes weighing care with out-of-pocket costs "is to consult with a health professional – preferably their primary care provider – to receive timely advice about the necessity of the care in question. Consultation by telephone, email, and nurse hotlines are all approaches I have seen. The potential financial burden of care could be even greater if patients have family members under the high-deductible plan who also need care, but this should not change the decision to quickly get expert advice about the need for care."

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